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1 - <br /> WELL PERMIT APPLICATION FOkM' SITE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IiIiI ON <br /> UNIT V <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) T IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services,Environmental Health Division. <br /> Assessor's <br /> WELL Location /34 5 7j4 CGNTkFA STK6.0T Cross Street b//}SHIn/41a�J SrCity S SLC T-0/J Zip 95202 Parcel# i A -300-Ut2 <br /> PROPERTYOwner CurY OF_'?l6CKTO,'J AddressJ164 ELDb Ar,(-, cr,ce6 - City 5r_0C C anJ Zip96202 Phone# <br /> C-57 ContractorC-19564DQ\1.1.1Nfa Address 950 40W6 120h0 City ±f-IINE;'bZipqit63Lic#! J Phonei(_g26-) 613-5-YOD <br /> au LTIE <br /> Consultant/Sub Contractor 5ECo(L INTI fWA:loAJhLAddress 301 • K1L60jZZ9D jouCity jkt o Lic# Phone#e'I(o) Yt¢I"04cO <br /> UP(400—v it <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER') []DESTRUCTION(choose type below) <br /> SOIL BORING# I (-LPT) Y �ZT/ 6 a OVER-BORE <br /> gWELL# -s �n1 []PRESSURE GROUT <br /> `Other: Grout Specifications: ciarn q-r <br /> COMMENTS: <br /> TYPE OF WELL qWL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> DIA.OF BOREHOLE Z,_ I ZMULTIPLE CASINGS?[]YES ,ANO WELL CASING DIA:Z'-4 <br /> EXTRACTION []AIR HAMMER/DRIVEN CASING THICKNESS Sck 40&TYPE OF CASING: []STEEL ;WVC []OTHER: <br /> []VAPOR []MUD ROTARY DEPTH OF GROUT SEAL" 2D'- 96TREMIE TYPE TO BE USED: []AUGERS 'HOSE <br /> p AIR SPARGE PUSH POINT GROUT SEAL PUMPED: , Yes Q No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> I(SOIL BORING(1) HAND AUGER GROUT SPECIFICATIONS: I<3ENTCWjTE t- e6PLILAND cE'mr1V7' <br /> Q OTHER: KOTHER CP-f Jtr� APPROX.BORING``DEPTH^'34' -' qO' I60LTED TRAFFIC BOX or O STOVE PIPE <br /> CONDUCTOR CAS1�[JG PROPOSED? NO (if YES,list specifications here): <br /> 'COMMENTS: 4 J ' ` -oy <br /> CP'f r kq 6a -TD I/ <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITt. ' <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordin aces, Rules d Regulations, and all applicable California State Laws. <br /> Signed x Title/Company A-66OK- 1AJT@e4q L <br /> Print Name $4eKe\II5 L-1Ai46 Date_ 3 �• <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE,ADDRESS: 1 3 3 So a+k Ce mi-ew <br /> WORKPLANDATED:_ Jtlrl&- ,24 X003 +e ugork p1jin d&k,4 *peebtl�o,.3p 7np� <br /> i <br /> Application Accepted By L d4 r+nDate Issued_MLI mG 5 2-D 0 4 Area 1 4 S9 <br /> Grout Inspection By� i c Date—Al Final Inspection By•{1i,.erh '.o yj AP12sTDate !d4 <br /> Destruction Inspection By Date 1l of <br /> COMMENTS/CONDITIONS: l <br /> ACCOUNTING ONLY: AID# <br /> cerIf <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT/SERVICE REQUEST# INVOICE <br /> 35 if 89.0:7 04 sR# 0 ,317 112 <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc 9/27/00 <br />